Friday, September 29, 2006

Speaking of transparency (see below), the Los Angeles Times reported in June that 20 percent of U.S. transplant centers were found to be substandard, in part because of a failure to perform enough operations to ensure competency. Here is the link to that story.

In New England, only BIDMC and MGH perform over 100 kidney, liver, and pancreas transplants per year, based on data collected by the United Network for Organ Sharing, UNOS, the national organization that monitors such matters. Several other hospitals perform only two or three dozen.

If you needed a liver transplant, would you be willing to travel an hour or two to go to a transplant center that was more experienced? If insurance companies care about clinical results, shouldn't they be directing patients to those centers with more experience and better results?

In the health care world, it has become fashionable to be in favor of "transparency," which roughly means public access to how well providers deliver care and what they charge for it. I agree with this. Health care is one of the few industries in which consumers do not see this information, and it is time to change that.

There are two ways to provide information on how well providers deliver care. One is based on processes, e.g., what percentage of emergency room patients with chest pain are advised to stop smoking (yes, that is one that is commonly collected.) The other is based on results, e.g., what percentage of cardiac surgery patients survive. Both can be important, but is obviously the latter that most consumers will care about. I am in favor of publication of both of these kinds of data, but especially the latter.

The price issue is more problematic. Hospitals and doctors don't get to set their own prices. These are negotiated with insurance companies. Recently, two CEOs of insurance companies in Massachusetts, Charlie Baker of Harvard Pilgrim Health Care and Jim Roosevelt of Tufts Health Plan, were heard to say or were quoted in the newspaper as being in favor of posting the prices that hospitals and doctors charge. Did they really mean that? This would mean that HPHC and Tufts would have to disclose to the world the rates that they have negotiated with BIDMC, Mass General Hospital, New England Medical Center, and the like -- in addition to the rates they pay different groups of physicians. In the past, sharing and publication of these rates was not permitted and was actually a violation of anti-trust laws.

Let me make it clear. We would LOVE to have those prices made public because we believe it would make clear that the largest player in our market, Partners Healthcare System (the owner of MGH, Brigham and Women's Hospital, and several others), gets higher rates because of its market dominance. We would rather have rates based on the quality of patient outcomes -- where the providers that achieve better results would be paid better. Maybe that is what Jim and Charlie are hoping for, too, so they can get out from under the market power of Partners and so consumers could make more rational choices about where to get their care. Maybe they believe that the best way to achieve it is for the state to order them to post their prices. Whatever their motivation, they deserve our support.

Monday, September 25, 2006

A note from one of our staff members. Most of us never have to think about such things. I hope it does not get you too upset:

"A small group of providers here performs above-and-beyond assistance to families that is little-known but beyond value. When a pregnancy fails and a baby dies in utero or is delivered stillborn here, clinical providers (MD's, nurses, social workers) strive to recognize the loss with the family, and to help them create mementoes of their baby. Almost always, the mementos that are most cherished by parents and famililes are photos of their infant. Our Media Services department staff go to Labor and Delivery and to the morgue to take professional quality black and white photos of these infants. Their skill, caring and attention to detail result in images that are often beautiful, despite the loss of life and occasional disfigurement, and are treasured by the bereaved families.

"When a family requests to see an infant after he or she has been transferred to the morgue, Pathology staff members locate and prepare the baby for viewing by the family. This is not a task listed in their job descriptions, and making this available to families means putting aside other pressing work, but they understand the importance of this last good-bye to some family members.

"Even for those providers whose clinical duties include exposure to neonatal death with some regularity, work with bereaved parents of infants is wrenching. Preparing the babies means handling them, and an inevitable confrontation with the tragedy of their deaths. These special efforts of the Media Services and Pathology staff are an extraordinary example of BIDMC employees giving of themselves for the benefit of our patients. "

Saturday, September 23, 2006

A lot of people have written to say they don't really know how to use a blog. It's simple; you just need to know where to click.

A blog is basically someone's online diary, except that others can add their comments. I start a topic by posting an initial message; others (you) add comments.

There are many different types of blogs on the Internet. I use a popular one called Blogspot. Here's how it works.

Underneath each of my initial posts is a note "3 COMMENTS," "12 COMMENTS," etc. Click that note to read the comments or add one of your own. A new window will open up, where you can read the comments and add one.

To add a comment you'll need to register, which takes a couple of minutes. You don't need to show your name publicly (you can post as Anonymous or any nickname), but the registration info (behind the scenes) is a way of having people be responsible for their posts. (It avoids spam-like posts or "hit-and-run" flaming messages.)

I very much hope you'll contribute. Dialog is the whole reason I started this blog. I want to share my thoughts and I want to know yours.

I sent an email to a bunch of friends to let them know about this site. Here are some of their reactions, which include a lot of advice about what to include, how to write it, and so on. (Lots of them didn't know how to reply to the blog itself, so I have copied their comments from emails they sent me.)

Sunday, September 17, 2006

Our doctors and nurses are so dedicated to taking care of patients that I sometimes have to remind them to spend time with their own families, ironically, particularly during times of medical crisis. Recently, a relative of one of our medical staff was diagnosed with a terminal illness, and the staff member was torn between a desire to be with the relative and a sense of obligation to patients at BIDMC. I advised this person that colleagues at the hospital would cover and that s/he should spend every available moment with the family member. I recently received the following bittersweet note just after the family member died. (I have removed details which might identify the people involved.) It has lessons for us all.

Dear Paul,I want to thank you for your words of encouragement and admonition to forget about work for a while. My [relative] died on Thursday afternoon, only a month after s/he was diagnosed. I spent most of the month here with a couple of quick trips back to Boston and I have no regrets. My [relative] was the best friend I could ever have asked for. We had a lot of quality time together during the past month. S/he saw all the grandkids, brothers and sisters, close friends, and had time to get all affairs in order to his/her satisfaction. We got some video telling some of his/her best stories and many pictures with family and friends that will be special memories forever. We had a lot of time to talk about the past and future, joke and laugh about any number of fun experiences too. We were truly blessed by the local hospice; their service and compassion was nothing short of incredible. My [relative] died a peaceful death with dignity and with my sister and me at the bedside holding hands and telling him/her how much we loved him/her. S/he was comfortable and ready. I must also say that I am truly blessed to have friends and colleagues that I can depend on to carry on at work without me having to worry, check in, solve problems, etc. Everyone at BIDMC has been supportive, and they have made this time one in which I could really focus on what was important.